CONSOLIDATED APPLICATION FORM for (See rule 17) 1) Setting up of units in Special Economic Zone; 2) Annual permission for sub-contracting; 3) Allotment of Importer Exporter Code Number; 4) Allotment of land/industrial sheds in the Special Economic Zone; 5) Water Connection; 6) Registration-cum-Membership Certificate; 7) Small Scale Industries Registration; 8) Registration with Central Pollution Control Board; 9) Power connection; 10) Building approval plan; 11) Sales Tax registration; 12) Approval from Inspectorate of factories; 13) Pollution control clearance, wherever required; 14) Any other approval as may be required from the State Government Form - F The application should be submitted to the Development Commissioner of the concerned Special Economic Zone in 5 copies alongwith a crossed Demand Draft of Rs. 5,000/- drawn in favour of the Pay & Accounts Officer, of the concerned Special Economic Zone together with a project report giving details of activities proposed. For Official use only Application No. Date / / Date Month Details of Bank Draft Amount Rs. Draft No. Draft Date Drawn on (Name of the Bank) Payable at PART I I. Name and full address of applicant firm/company (in block letters) Name of the applicant Firm/company Full Address (Regd. Office in case of Limited Companies & Head Office for others) Pin Code Tel.No. Fax No. Permanent E-mail Address 1
Web-Site, if any Passport No., if any Name of Bank with Address & a/c No. Digital Signature (Yes/No) Income Tax PAN (attach copy) II. Constitution of the applicant firm: (Please click/tick the appropriate entry) Government Undertaking Public Limited Company Private Limited Company Proprietorship Partnership Others (Please Specify) (Attach copy of the certificate of incorporation alongwith Article of Association and Memorandum in case of companies and Partnership deed in case of partnership firms) III. Nature of the industrial undertaking: (Please click/tick the appropriate entry) i. Large Scale ii. Medium Scale iii. Small Scale IV Sl. No. 1. 2. 3. 4. 5. 6. Name and complete address of each of the Directors/partners/ Proprietor, as the case may be with telephone No. Name Address Telephone No. V. ITEM(S) OF MANUFACTURE/SERVICE: (Including By-product/Co-products) (If necessary, additional sheets may be attached) Item(s) Description Capacity (Unit = ) Item Code (ITC HD Code No.) (Note required for service unit) VI. INVESTMENT 2
a) Plant and machinery i) Indigenous ii) Imported (CIF Value ) (iii) Total (i)+(ii) b) Details of source(s) of finance Rs. In lakhs US $ thousand VII. Import and indigenous requirement of materials and other inputs (Value in Rupees lakhs) Import Indigenous a) Capital goods b) Raw material, components, consumables, packing material, fuel etc for 5 years Total (Give details in project report, namely list of capital goods, description of raw materials, and other inputs, etc) VIII INFRASTRUCTURE REQUIREMENTS 1. Requirement of Land:- (Area in sq. mtrs.) i. Factory & Officers ii. Warehousing/storage iii. Others, specify 2. Requirement of built-up area 3. Requirement of Water (In Kilo Litres) i. For industrial (process purposes ii. For drinking purposes iii. Others, specify iv. Total requirement 4. Effluent Treatment i. Quantum and nature of effluents and mode of disposal ii. Specify whether own Effluent Treatment Plant will be created 5. Requirement of Power (in KVA) IX Employment Men Women X WHETHER FOREIGN TECHNOLOGY AGREEMENT IS ENVISAGED (Tick the appropriate Entry) Yes No (i) Name and Full Address of foreign collaborator (ii) Nature of collaboration 1. Equity participation including Investment ($ in thousand) (Rs. In lakhs) i) a) Authorised b) Subscribed 3
c) Paid up capital Note: If it is an existing company, give the break up of existing and proposed capital structure ii) Pattern of share holding in the paid-up capital (Rs. In lakjs) (US $ Thousand) a) Foreign Holding b) Non Resident Indian company/individual holding i) Repatriable ii) Non-repatriable c) Resident Holding d) Total Equity e) External Commercial Borrowing (Give details) 2. Technical Collaboration (Furnish details in project report (Gross of taxes Rs. In lakhs) a) Lumpsum payment b) Design & Drawing Fee c) Payment to foreign technician d) Royalty (on exports) % e) Royalty (On domestic tariff Area if envisaged) f) Duration of agreement s 3. Marketing Collaboration (Furnish details in project report) XI. FOREIGN EXCHANGE BALANCE SHEET 1st 2 nd 3 rd 4 th 5 th Rs. Lakhs Total US$ Thous. 1. FOB Value of exports in first five years 2. *Foreign Exchange outgo for the first five years 3. Net Foreign Exchange Earnings for the first five years (1-2) * Foreign exchange outgo shall include the CIF value of import of machinery, raw material, components, consumables, spares, packing materials and amount of repatriation of dividends and profits, royalty, lump sum know-how fee, design and drawing fee, payment of foreign technicians, payment on training of India technicians abroad, commission on export, interest on external commercial borrowings, interest on deferred payment credit and any other payments. XII. OTHER INFORMATION 4
(i) (ii) Whether the applicant has been issued any Industrial license or LOI/LOP under EOU/SEZ/STP/ EHTP scheme. If so, please give full particulars especially reference number, date of issue, items of manufacture and progress of implementation of each project Whether the applicant or any of the partners/directors who are also partners/directors of another company or its associate concerns are being proceeded against or have been debarred from getting any Lincese/letter of Intent/Letter of Permission under the Export and Import (Control) Act, 1947/Foreign Trade (Development and Regulation) Act, 1992/FEMA/Custos/Central Excise Act. Place Date Official Seal/ Stamp Signature of the applicant Name in Block Letters Designation Tel No. E-Mail address Website, if any Full Residential Address UNDERTAKING I/We hereby declare that the above statements are true and correct to the best of my/our knowledge and belief. I/We will abide by any other condition, which may be stipulated by the concerned Development Commissioner. I/We fully understand that any Permission Letter granted to me/us on the basis of the statement furnished is liable to cancellation or any other action that may be taken having regard to the circumstances of the case if it is found that any of the statements or facts therein are incorrect or false. An affidavit duly sworn in support of the above information is enclosed. Place Date Official Seal/ Stamp Signature of the applicant Name in Block Letters Designation Tel No. E-Mail address Website, if any Full Residential Address Note: Format of application not given herein may be obtained from the Development Commissioner. 5
PART II If sub-contracting is envisaged in the manufacturing operations, furnish following details:- i. Sub-contracting permission is required for a) Part of the production process b) Any particular production process (Give Details) ii. Name and address and other particulars of sub-contractor and whether the subcontractor is a) Domestic Tariff Area unit/central Excise registered or otherwise b) Other Special Economic Zone unit c) Export oriented unit or Electronic Hardware Technology Park unit or Software Technology Park Unit 6